MOLST to POLST Advisory Group

In March 2021, Massachusetts officially began the important work of transitioning our current paper-based MOLST Program to the much improved POLST (Portable Orders for Life- Sustaining Treatment) electronic form and statewide electronic registry. These changes, which we’re calling the MOLST-to-POLST process, hold the promise to make our program an even more powerful, inclusive, transparent and meaningful tool for caring for the seriously ill. But we need to come together as a community in order to make that vision a reality.

The Coalition is partnering with the state to support this effort and has formed a MOLST to POLST Advisory Group that brings together healthcare and community leaders to synthesize their collective knowledge and share their diverse stakeholder experiences. Together we will identify critical issues in our current MOLST program and offer best practice recommendations to transition to a successful, sustainable POLST Program.

Contributions from Blue Cross Blue Shield MA and the Coalition helped the Massachusetts Executive Office of Health and Human Services secure matching funding for the registry from the Centers for Medicare and Medicaid Services.


Resources


Frequently Asked Questions

POLST is part of advance care planning intended for people who are seriously ill or who have advanced frailty. It starts with a conversation between the patient and their health care provider regarding the patient’s medical condition, treatment options, and what the patient wants for care, and can lead to transferring patient treatment choices onto the POLST form.

With stakeholder guidance, we can build a much improved POLST Program where conversations between clinicians and patients, Health Care Agents and Guardians are at the center of the process. The POLST Program will include key implementation components such as:

  • Professional training & education for clinicians & care teams
  • Consumer education for adults, families, caregivers, legal advocates
  • POLST orders that are immediately available 24/7 through an electronic registry, in particular to First Responders who require signed orders in order to provide selective or comfort-focused treatments.

Some of the specifics of the POLST Program implementation are still being determined. It is likely that there will be an extended period of time where paper MOLST forms are honored even after the implementation of the POLST registry to allow time for transition and to best support the care of our patients. POLST forms that are completed in the electronic registry will also be able to be printed. Provide your input into the process here.

While the e-registry is meant to allow POLST forms to be accessible at critical moments and moments of care transitions, individuals may still choose to keep a printed version of their POLST form in their home for easy reference for themselves, people who matter in their lives, and any care provider who may need it.

The State and the Auribus Consulting team are working hard to develop an implementation plan for successful rollout of the many pieces of the POLST Program (e.g. messaging, training, registry implementation, evaluation). The focus of the first phase of work has been to assess the current MOLST process from the perspective of key stakeholders, develop a future state blueprint of a POLST Program, and facilitate procurement of an electronic registry. The procurement documents are currently in the review process with the State. We will provide updates as they become available.

While the specifics of the implementation of the e-registry are still being determined, it is likely that there will be an extended period of time where MOLST forms are honored even after the implementation of the POLST registry to allow time for transition and to best support the care of our patients. Best practices for POLST include regularly verifying and updating MOLST/POLST forms with individuals when changing providers, at care transitions, when there is a substantial change in health status, and when a patient’s goals or care preferences change. These moments would present opportune times to transition a patient’s care preferences from a MOLST form into the POLST e-registry.

A core component of a successful POLST Program implementation will be training all stakeholders on the POLST form, the e-registry, and best practices around having conversations about what matters most to individuals, translating these conversations into care preferences, and honoring these preferences. We would love your input on what pieces of training are most important for your colleagues and care setting.

In April 2020 during the COVID-19 State of Emergency, the State waived the standard for written signatures by patients/ legal advocates on a MOLST form as it was not possible for patients and clinicians to have in-person planning conversations and sign a MOLST. At that time, the State authorized care providers to complete a MOLST form using Witnessed Verbal Consent to allow clinicians and patients to have goals of care discussions via telehealth and document patient choices.

As of May 12, 2021, EMS Protocols state the standard for a written signature by patients/legal advocates on the MOLST form has been reinstated and verbal is no longer accepted. However, there is an exception if the patient is in a licensed care facility. Please read Updated EMS Protocols here.

Importantly, a MOLST form completed with witnessed verbal consent from April 3, 2020 to May 11, 2021 will be considered VALID by EMS. We understand that this was a helpful tool for many, especially in a time of increased virtual visits. Many existing e-registry platforms allow for digital signatures, which can help with POLST completion during remote visits in certain situations. Please provide your input into this process.

No. HIPAA supports the free exchange of medical information necessary for treatment between clinicians and health systems. The current MOLST form states: “HIPAA permits disclosure of MOLST to health care providers as necessary for treatment." In Oregon, their form extends that statement to read “HIPAA permits disclosure of POLST to health care providers and electronic registry as necessary for treatment.”

A POLST form is a portable medical order. The POLST form tells all health care providers what a seriously ill or frail adult wants during an emergency and what their goals of care are given their current medical condition. The POLST form is signed by both the patient and the clinician. The POLST form travels with the patient and should be followed by licensed clinicians in all care settings. Massachusetts is adopting the National POLST form developed by National POLST.

Massachusetts DHS made the decision in 2019 to switch to the National POLST form. This form is based on best practices learned from research and mature programs around the country and is designed to simplify and better facilitate the translation of a patient's care preferences into medical orders. By adopting the new form, Massachusetts aligns with national standards and benefits from reciprocity with other states using the National form. The form has been adopted by Maine and New Hampshire, and it's being considered by Connecticut and Rhode Island. The National POLST form includes treatment orders for:

  • Cardiopulmonary Resuscitation: Attempt or not attempt
  • Scope of Treatment: Full Treatments, Selective Treatments, Comfort-Focused Treatments
  • Medically Assisted Nutrition: Yes, No, Trial, Undecided

Here’s the sample POLST Form

No. POLST orders are NOT intended to replace communication between health professionals and patients, Health Care Agents, or Guardians. POLST orders should be accessed and followed when a patient is not able to speak for him or her self. For example, if a patient becomes unresponsive and 911 is called, EMS responders should access the patient’s POLST and follow the orders accordingly.

In contrast, when patients are able to speak for themselves and make their own medical decisions, POLST orders should be re-confirmed during transitions of care. For example, when a patient goes from a nursing care facility to a hospital, the admitting clinician should review the POLST form with the patient and confirm that the orders still represent what care the patient wants. When patients are not able to speak for themselves or make their own medical decisions, clinicians should re-confirm POLST orders with their Health Care Agent or Guardian.

No. POLST must always be voluntary for the patient, the Health Care Agent and Guardian. If you are forced or required to complete a POLST form, this violates patient self-determination, informed consent, and the principles of person and family-centered care. Patients have a right to participate in medical decision-making regarding their treatment plan, including the choice of saying they do not want a POLST form. Organizational policies and procedures in any care setting should never require adults to complete a POLST form.

Section A and B are designed to provide clarity for EMS providers who must be able to act quickly and decisively in an emergency. They proceed along the lines of BLS protocols:

Section A: Only if the patient has no pulse and is not breathing. Either Yes CPR, or No CPR. If the patient has a pulse and is breathing, move to Section B.

Section B: The patient has a pulse and is breathing, but is in crisis.

  • If Full Treatments: transport the patient to hospital; if necessary, intubate the patient.
  • If Selective Treatments: transport the patient to hospital; if necessary provide oxygen, non-invasive airway support, but do not intubate the patient.
  • If Comfort-focused Treatments: provide oxygen, medication, and any other available treatment for comfort; do not intubate the patient. Transport the patient only if they cannot be kept comfortable where they are at.

Importantly, patients with an order to attempt CPR should also have an order for Full Treatment. Many patients who receive CPR will end up intubated and in the intensive care unit, which equals Full Treatments. It does not make sense to have an order for Selective Treatments that does not allow intubation, but instructs EMS to perform CPR, which includes intubation, if the patient is no longer breathing. Finally, an order for Comfort-focused Treatments and a goal of allowing natural death should not be combined with an order to attempt CPR.

While Full treatment combined with No CPR may seem incongruent, it is not. It means that all effective treatment efforts to prolong life should be provided including intubation and ICU care. However, if the patient loses their pulse or stops breathing, treatment should not be escalated to include CPR, or, at that point if they are not already intubated, intubation.


Advisory Group Members

Jon Burstein, MD, FACEP, FAEMS
Medical Director, State Emergency Medical Services (EMS)
Office of EMS, MA Department of Public Health

Ellen DiPaola, Esquire
President & CEO Honoring Choices Massachusetts
National POLST Plenary Assembly
Co-Chair, MOLST to POLST Advisory Group

Lachlan Forrow, MD
Co-chair (2009-2011), Massachusetts Expert Panel on End-of-Life Care
Chair (2015- ), Massachusetts DPH Interdisciplinary Advisory Council on Palliative Care and Quality of Life

Erik Fromme, MD, MCR, FAAHPM
Senior Scientist/Lead Faculty, Serious Illness Care Program
Brigham and Women's Hospital | Harvard T.H. Chan School of Public Health
National POLST Quality Assurance
Co-Chair, MOLST to POLST Advisory Group

Anna Gosline
Executive Director, Massachusetts Coalition for Serious Illness Care
Senior Director of Strategic Initiatives, Blue Cross Blue Shield of Massachusetts

Tara Gregorio
President, Massachusetts Senior Care Association

Jennifer Kaplan
Senior Attorney, Center for Public Representation

Christine McMichael
Executive Director, Hospice & Palliative Care Federation of Massachusetts
National POLST Plenary Assembly

Patricia M. Noga, PhD, RN, NEA-BC, FAAN
Vice President, Clinical Affairs, Massachusetts Health & Hospital Association

Jennifer Reidy, MD, MS, FAAHPM
Chief, Division of Palliative Care, UMass Memorial Medical Center
Associate Professor, University of Massachusetts Medical School
Program Director, UMass Palliative Medicine Fellowship

Eric Reines, MD, FACP
Element Care PACE
Massachusetts Medical Society

Erica J. Wilson, MD
Equity Director, MGH Division of Palliative Care and Geriatric Medicine
Technology and Learning Lead, MGH Continuum Project

Updates

  • As a first step in the transition, the Executive Office of Health and Human Services (EOHHS) and the Executive Office of Elder Affairs has engaged Auribus Consulting to assess the current MOLST process from the perspective of key stakeholders, develop a future state blueprint of a POLST Program, and facilitate procurement of an electronic registry.
  • The team from Auribus Consulting met with over 100 stakeholders from across the state to inform the first phase of work and development of the RFR for the procurement of the electronic registry.
  • The MOLST to POLST Advisory Group shared recommendations on a first round of key questions with the Auribus Consulting team. Read the recommendations here.
  • Over 100 people joined a great discussion session Meet & Greet the POLST Form, representing many stakeholders and care settings that interact with POLST. See the video below. Please let us know if there are specific topics you want to discuss or groups of people we should be hearing from!

Events


Share Your Ideas!

We want to hear your thoughts and feedback on the MOLST to POLST transition.

Share Your Ideas Here!